Meriden Humane Society Canine (Dog) Request to Surrender Form

Please fill out this form to add your canine to our evaluation and intake waiting list.

Owner Information
Who is requesting to surrender?

First Name *
Last Name *
Street Address * Ex. 123 Test St. Apt 465
City *
State *
Zip Code *
Cell Phone * Ex. 123-456-7890
Home Phone Ex. 123-456-7890
Email Address *

Canine Information

Canine Name *
Gender *
Species *
Breed *
Canine Age? Ex. 1yr 4mo * Ex. 1yr 4mo
Canine Size *
Is your canine microchipped? *
Is your canine spayed or neutered? *

Up to date on shots:

Up to date on Rabies? *
Up to date on Distemper? *
Up to date on Bordetella? *

Vet Information (Name and Phone#)
Are you able to provide vet records to support vetting history? (Please Note: In order to expedite the surrender process, please contact your vet and give them permission to provide vetting information on the animal in question) *
How long have you had your canine? Ex. 3yr 3mo *
Did you adopt your dog from the Meriden Humane Society? *
Did you adopt your dog from another rescue or breeder? *
Name and State of organization *
Have you contacted the organization/breeder?
What was the date of contact and the response of the organization? If they are not willing to accept the animal back, please state their reason.

Does your canine have any medical issues? *
If yes, what is his/her condition(s)?
Behavioral Issues

Food Aggression? *
Other Canine Aggression? *
Feline Aggression? *
Good with children? *
Toy Aggression? *
Other types of aggressions noted?

Why are you choosing to surrender your canine? *
What is the best way to contact you? *

Please Note: Filling out this form does not guarantee you an evaluation appointment. As of 12/1/2018: MHS requests a $100 canine surrender donation.